Provider Demographics
NPI:1083817373
Name:WIDEMAN, JD (DO)
Entity Type:Individual
Prefix:DR
First Name:JD
Middle Name:
Last Name:WIDEMAN
Suffix:
Gender:F
Credentials:DO
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Mailing Address - Street 1:3702 AUTOMATION WAY
Mailing Address - Street 2:SUITE 103
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-5737
Mailing Address - Country:US
Mailing Address - Phone:970-224-1670
Mailing Address - Fax:970-495-6218
Practice Address - Street 1:3519 RICHMOND DR
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-5995
Practice Address - Country:US
Practice Address - Phone:970-204-0300
Practice Address - Fax:970-221-5206
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO47085207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCO303242OtherMEDICARE ID
CO61706078Medicaid